Video: Casodex, SpaceOar, and Biopsy Reports | Ask a Prostate Expert
Ask a Prostate Expert | Transcription
Alex: Hi, I'm Alex with the PCRI and I'm here with our Executive Director, Dr. Mark Scholz. I'm representing the PCRI Helpline today, and we are here to ask your questions to a full-time prostate oncologist. So, I'm really enthusiastic about being here. It's an honor to be able to ask your questions to an expert, and we'll get right into it.
How are you doing today?
Dr. Scholz: I'm doing great!
Alex: Are you ready to start an entire new Youtube series based on all prostate questions 24/7.
Dr. Scholz: Well, I answer questions all day long, so this is fun. Most of the time, it's with elderly people, usually males, but…
Alex: You just have to pretend I'm like a 70-year-old average male coming into your office. Don't I look like it? I think I can try to pull it off.
Dr. Scholz: I do have to pretend that because I presume the people that are listening to us are of that genre.
Alex: Yeah, I think so.
So, our first question is about Casodex, and these questions actually came from the search engines on our website, so we know that people have been looking up Casodex on our website, and this question particularly caught my eye because I like the way the person asked it. It was, "Casodex, why is it added to everything?" So, basically, he's asking "Why is, like, my brother and my third cousin twice-removed on Casodex too? Like, it's everywhere."
Dr. Scholz: Well, Casodex was one of the first medicines that was FDA-approved to help men with prostate cancer. It's a pill, once a day, very well tolerated. It doesn't usually cause much of any side effects if people are already on Lupron. And when they're talking about adding Casodex, they're usually talking about adding it to Lupron or a Lupron like drug. So, the early trials showed that men that took Casodex in addition to Lupron lived longer. Now, it wasn't a big difference in survival, but it was a difference. And, the only reason it just didn't become a universal for Lupron forever is that it was really pricey when it was first approved. But now it's generic, it's very accessible, and so it still is the policy to give Casodex for at least a month when people are starting on Lupron. Lupron can cause a temporary rise in testosterone which is considered undesirable, obviously, for men with prostate cancer. So, by being on the Casodex during that flare period, they are protected from the rise in testosterone. Now, some have been recommended stopping the Casodex and the original decision to stop it after a month or so was to save money. So my policy is usually, yes, leave them on the Casodex as long as they're on the Lupron, and the additional anti-cancer efficacy added to the Lupron is useful, and it doesn't usually cause any additional side effects.
Alex: So, for instance, when I Google Casodex, it comes up as a hormone treatment and it comes up as a chemotherapy treatment. Can you explain to the audience why that is?
Dr. Scholz: Yeah, the idea of Casodex as chemotherapy is more of a billing issue. The way that Medicare coded Lupron and Casodex early on was as "chemotherapy," and that's just because it's a medicine to treat prostate cancer. But when we think of chemotherapy, we're thinking of injectable medicines that cause hair loss, that can cause nausea, and so the idea of it being a chemo is actually ridiculous. But yes, that's a carryover from some goofy billing issues, and sometimes you'll still see that. They're calling it a type of chemotherapy, which in reality it's nothing of the sort.
Alex: Okay, and another thing when I was researching Casodex, I saw the side effects of Casodex, and some things it mentioned were like bone and pelvic pain. Why would Casodex cause that? Is that accurate?
Dr. Scholz: Well, usually the side effects of Casodex are very close to what Lupron causes only typically milder. And I'm talking about using Casodex in conjunction with Lupron, not Casodex as a single agent—we can talk about that separately. But when it's used in conjunction with Lupron, there may be a slight increase in fatigue. Men do need to be monitored for rare problems with their liver, and this is tested with a blood test about 4-6 weeks after someone starts on the Casodex.
Alex: What type of blood test is it? I mean, what's the name?
Dr. Scholz: Yeah, the blood test is called a Hepatic panel, and so typically after someone begins hormonal therapy, they'll come back to the doctor's office after 4-6 weeks, and they'll be tested for any liver abnormalities with a Hepatic panel and they'll also have another PSA to make sure the treatment is working, perhaps check the testosterone level to make sure that the testosterone is lower as would be expected from the Lupron component of the treatment, and those tests, usually, are very routine and we rarely see problems. But, there's a rare case, maybe 1% of people the Casodex can cause some irritation of the liver. You'll see that with elevations of two blood tests called AST and ALT, and then the Casodex needs to be stopped and it will reverse, and so because you're picking it up in a timely fashion. If the Casodex was continued without monitoring and in those rare patients that have problems, it could become dangerous.
The other thing to mention with Casodex, because sometimes Casodex is used by itself as a standalone treatment because it's milder than Lupron, and it's very convenient, it's a pill, it reverses much more quickly than Lupron. But one thing that happens because testosterone is not completely eradicated, all that testosterone can be converted into estrogen which translates into breast tenderness and breast enlargement. So, men that are taking Casodex by itself need to take some sort of preventative measures, either do radiation to the nipples prior to treatment or take an aromatase inhibitor such as Femara or Arimidex and that stops the conversion of testosterone into estrogen.
Alex: So, our next question is "What is SpaceOAR?" I think there is a lot of marketing going around, what SpaceOAR is, and a lot of patients have questions, and not only what is it, but the patients who know what it is, "How do I get it?" So…
Dr. Scholz: SpaceOAR is a very clever new technology. They can inject a gel substance between the rectum and the prostate and push the rectal wall as much as a half an inch away from the prostate, and this is a really wonderful thing because historically the radiation therapists were obligated to treat a portion of the rectum because it was right on the edge of the prostate and a small percentage of people would get burns there from the radiation and in some cases it would never heal. This is called radiation proctitis and it can be disastrous. So, skillful doctors over the years have really learned to minimize radiation proctitis, but as you know, not all doctors are equally skilled, and so SpaceOAR is a nice way to kind of take out an insurance program against getting a rectal burn. It's administered through an injection through the perineum, so it's a little uncomfortable when it's put in.
Alex: Do they numb it?
Dr. Scholz: Yeah, they numb it up and, you know, there is a skill factor in putting SpaceOAR in. You probably want to look for a doctor that has done a number of them. Many times the radiation therapists, themselves, know how to put the SpaceOARs in, or they may refer to a urologist that they work closely with and he would put the gel in, you know, a week or two prior to doing the radiation treatment. The beauty of the technology is that after about ninety days, the gel just absorbs and turns into water and disappears. So, the radiation therapy, now, is given over anywhere from a two-week to a nine-week period, so that allows plenty of time for that distance to remain and then after the radiation is finished and it's no longer needed, it spontaneously regresses.
Alex: Got it. So when it dissolves, like how does it go out of your body?
Dr. Scholz: So it turns into water and then the previous little cushion or pillow of gel that was there just disappears.
Alex: Oh, that's cool. That's really cool. And it's just two types of gel compounds they mix together and it takes about, what, twenty minutes to do the procedure?
Dr. Scholz: Yeah, if it's done adroitly and skillfully, it can be done in twenty minutes. I've seen a few of these done. I mean, the men are up in Trendelenburg if you women out there remember pelvic exams, so it's very personal and intimate when you have a SpaceOAR put in. The needle goes between the scrotum and the anus, so the guy is sitting there with his legs up and then the needle goes in and they have an ultrasound in the rectum so they can see where they're going, and then the actual injection is done very quickly and probably just like five seconds they just push it right in and then it's all ready to go. So, the beauty of it is that this very frightening and potentially debilitating proctitis problem has been pretty much circumvented and we—I recommend it pretty much routinely. Even with the best doctors, it's just an extra layer of insurance to make sure that terrible side effect doesn't occur.
Alex: Yeah, I think definitely with just working at PCRI and being on the Helpline when we get calls from people who have radiation burns, it's just heartbreaking, and having to deal with the side effects of that and dealing with all that, I'm a huge fan of SpaceOAR. And I've talked to a lot of people that have had it and they said it was a pretty easy procedure. I had one guy, though, that was like, "I had a biopsy in the same place, so it's kind of like one needle? It's not that bad in comparison." So, I thought that was a really good way to look at it. But, I think one of the biggest questions we get so do any of these doctors put it in and where do I find someone? You know, how do I ask? Do I just call the office? I know that SpaceOAR.com has a finder and a locator that they can see. It's right on the front page of their website. Is there anything you tell your patients in particular?
Dr. Scholz: Well, I think if you're selecting your radiation therapist carefully, the really quality doctors out there are going to be familiar with it already and they will have a plan in place. It has been out long enough now and it's quite revolutionary so if you run into a doctor doing radiation that hasn't heard of SpaceOAR, maybe you better be looking for a different doctor.
Alex: Got it. And it's covered by Medicare and other insurances pretty well. To me, it's a very safe bet of what we should be doing.
Dr. Scholz: Yes, and I mean, talking about that issue with people with proctitis on the Helpline. I mean, there really isn't an effective treatment. They talk about doing hyperbaric oxygen because that may help a little bit, but it's mostly just keeping your fingers crossed and hoping and praying that it'll go away and it doesn't always go away. Sometimes it remains for the remainder of that individual's life. So we're talking about an incredibly sensitive area of the body being damaged and so it's a wonderful new technology.
Alex: The next question we had is, "How does someone interpret their biopsy report?" And, I think they get these numbers when they're newly diagnosed. They don't know what to do. There's like a plus sign in the middle of it. Does that mean it's better or worse? You know, so what does all of that mean?
Dr. Scholz: So that's a big question. We could probably do a few videos on that, but the main things that I look at when I look at a biopsy report—which is reporting out a random biopsy—usually people have had 12 separate sticks in their prostate and if it's a well-performed biopsy the doctor labeled where in the gland each stick came from. I still come across reports where they don't. They just throw all the cores; they remove cores into a bottle and they don't say where they came from. It's tragic because the information about the location of the cancer in the prostate is very useful, especially if someone is thinking about doing a focal therapy. If you want to just treat a section of the prostate to try and reduce your risk of erectile dysfunction and other side effects. So, we always look at how many cores have cancer in them out of the 12. We look at if there's, say, a couple of core involved—let's say two of the cores have cancer—we look at how much of the cancer within the core has cancer. Because when they stick the needle in, it doesn't mean it's gonna hit 100% cancer. It may hit the edge of a tumor or it may hit the center of a small tumor, and so each core—which can be, you know, three-quarters of an inch long, for example—may have a quarter of an inch of cancer and a half an inch of normal prostate tissue. So we look at the number of core involved. We look at the percentage of involvement of the involved cores. And so, you're already starting to get a sense of how big this tumor is. The number of cores plus the percentages sort of is this a tiny tumor? Is this a big tumor? Obviously, that's important. So that's important information from the biopsy report.
The other thing, of course, is the grade. You were talking about the plus and the minus and the problem with prostate cancer unlike, say, skin cancer is we use the number system instead of giving different names to the different types of cancer. In skin cancer, we have basal cell carcinoma which would be probably like a grade 6 prostate cancer and then we have the melanomas which maybe would be like a grade 10 prostate cancer. So, people think that there's sort of a smooth continuum, but really these different numbers are identifying different types of prostate cancer and as the number goes up the potential for spread, the potential for growing more quickly, and the potential for being resistant to treatment all go up as the number goes up.
So, the number, how many of the cores have cancer in them, what percentage of core involvement, and then—as we already mentioned—the location in the gland. There's a ton of information—useful information—that come from these biopsies and this is what people look at first, and they also look, of course, at how high is the PSA and in rare circumstances, they're looking is their cancer spread, with scans, outside of the [gland]. Those are incredibly important factors. But for most men being diagnosed with PSAs less than 10-15, the cancer is gonna be in the prostate and the big question is what grade is it and how big is it?
Alex: Right, right. So, how often, I mean, as far as the accuracy goes of these biopsies and the reading, like, do you suggest that people go get second opinions and get a secondary reading on these biopsies?
Dr. Scholz: For the most part, yes. The assignment of a grade is a skill and certain doctors do it more and they're better at it. The distinction between prostate tissue, like a normal core biopsy, and cancer, I haven't seen that mistake made. I mean, the doctors that are reading these, they can tell the difference between prostate gland and cancer, but the assignment of an accurate grade can vary, even among experts. So, one way to crosscheck the validity of a grade is with some of these new genetic tests like Prolaris, Oncotype, and Decipher, so that another independent way to look at how aggressive the cancer might be. And that's how we decide what kind of treatment to use, how aggressive the treatment should be. If it's a more aggressive cancer, more aggressive treatment; if it's a less aggressive cancer, milder treatment.
Alex: So, being the prostate expert that you are—being in the field forever—you know who the expert guy is that should look at these biopsies for a second opinion and that's Jonathan Epstein, right?
Dr. Scholz: We've been sending work—there's a number of good pathologists out there. Dr. Epstein has made it a very convenient way to just have your biopsy slides sent to John Hopkins, get them reviewed, and, of course, you know you're dealing with top-level pathologists. He's certainly not the only good pathologist in the world, but he's made it very easy to get crosschecked and he's got an excellent reputation as being one of the preeminent prostate pathologists in the world.
Alex: Right, so once a person gets that number, so maybe it's 4+3=7 and then they're in the teal stage, what should they do with that? Like, I know PCRI has, you know, a lot of resources on our website, so what can they do with that number to help contextualize their place in prostate cancer?
Dr. Scholz: I'd recommend that they use your resources to find out, for example, if they're a grade 7, we divide men into a Low, Basic, and High categories based on high their PSA is, how many biopsy cores because the treatment is going to vary even within—we call it—Teal—other people call it intermediate-risk—and you can go anywhere from a very favorable Low-Teal that someone could do active surveillance (just watch it) versus unfavorable intermediate-risk—what we call High-Teal—where someone should be treated with a combination of hormones for 4 months, a seed implant, and IMRT all in combination. So, the Teal category varies so greatly. A big part of that is the biopsy; is it a 4+3, is it a lot of cores involved, and that information is on your website.
Alex: Right, right. And you can take the prostate cancer staging quiz. So if you go to PCRI.org, there's a big "Take The Quiz" button, and you can put your PSA information, your Gleason score, and its six simple questions and it will identify you in the whole context of prostate cancer and it will identify you in what stage you're in, and once your stage is identified you can now be presented with information on the basics of prostate cancer, the treatments available specific to your stage, the side effects, and then any lifestyle issues that help build out a full picture of where you're at and options that really are important for you to know. And so, thank you so much Dr. Scholz. I really enjoyed this. I learned a lot. I'm very excited about this series because I get to get all my questions answered and it's an honor to be able to represent the Helpline and PCRI as we go into this. So thank you.
Dr. Scholz: Thank you.
Alex: Go ahead and subscribe to our Youtube channel. The subscribe button is right here on the bottom right of this video, and give up a thumbs up if you like the content. One of the big things that the PCRI is super passionate about is we want to answer your questions so go ahead and leave your questions that you would like Dr. Scholz to answer in future videos in the comments below. And you guys can go ahead and have conversations. If there's more information, you're like, "Oh, I like that person's question! We should add this." And we're gonna go ahead and our team is gonna read through that and you'll see it in future videos. And we're here, we're excited, and we love you at PCRI and we hope you have a great week.